Working with homeless patients can be exceedingly rewarding.
TALES FROM THE CLINIC
In this installment of Tales From the Clinic: The Art of Psychiatry, we examine the case of posttraumatic stress disorder (PTSD) in the setting of homelessness and substance use. Most homeless individuals report experiencing significant trauma at some point in their lives. This discussion examines the correlation between trauma and homelessness, and touches on vicarious trauma endured by treating physicians as well. It is easy to fall into negative perceptions of patients with homelessness, trauma, and substance use. Successful treatment hinges on remaining humane in perspective and viewing such cases as very high in comorbidity and needing additional psychosocial support.
“Ms Harris” is a middle-aged woman with a history of PTSD and alcohol use disorders who is currently receiving substance use treatment at a homeless shelter. She is engaged in a substance treatment program for the first time in her life.
Ms Harris was raped by an uncle at age 12 and advised by her mother to keep the incident a secret. After the rape, she started struggling with academic performance and she stopped attending school at age 16. She married at age 19 and quickly had 2 children. Her husband was physically and emotionally abusive in their marriage. She started drinking alcohol to cope with the abuse. She divorced her husband after 20 years of marriage when her youngest child turned 18. She received a small financial settlement after the divorce but had exhausted her savings after 3 years. She was unable to sustain employment because of her alcohol use and discomfort interacting with strangers. During this time, her alcohol use escalated and her relationship with her children became strained. After exhausting her financial resources, Ms Harris experienced significant alcohol withdrawal and was admitted to the medical unit for treatment. She was evicted from her apartment for nonpayment while inpatient and she was subsequently discharged to a local shelter and substance use rehabilitation program.
Ms Harris is seen by a psychiatrist after completing the first 30 days of her sobriety. She is visibly anxious with significant psychomotor agitation. She reports difficulty with sleep initiation as well as sleep maintenance. She finds interacting with her peers uncomfortable and isolates herself when possible. During the visit, she reports significant irritability, primarily triggered by her peers and loud noises. She also reports having taken escitalopram in the past with poor effect.
Distrust of others is a well-known symptom of PTSD. Childhood maltreatment—including emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse—is also associated with increased distrust as well as interpersonal threat perception in adulthood.1 This often presents a challenge to the therapeutic alliance. Engaging in the principles of trauma-informed care is critical to both establishing trust and avoiding retraumatization.2
During Ms Harris’ initial visit, she is reminded that her participation in the appointment is voluntary and confidential. Prior to giving a trauma history, she is advised that while she may be asked about broad categories of abuse, she can decline to answer any questions that make her uncomfortable and request that no trauma history be obtained at the initial visit. She is invited to provide any details that she does feel comfortable discussing, but is reassured that she will not be asked to divulge any painful details of her past. Ms Harris discusses that she had been sexually abused as a child and physically abused as an adult, but declines to provide further details during the first few visits.
During the initial interview, Ms Harris has some ambivalence about her alcohol use. While she understands that her use had escalated to an unhealthy level, she also reports that it was her primary means of coping with her anxiety. Without it, she reports a significant escalation of her symptoms. She worries about her ability to tolerate a substance use treatment program.
Ms Harris is not alone in her difficulties with alcohol use. Some studies show the prevalence of alcohol dependence in homeless patients to be upward of 55%, and similar rates of drug dependency.3 In emergency departments, rates of substance use were significantly higher, sometimes doubled, in homeless patients compared with those who did not report homelessness.4 While there are many hypotheses surrounding these findings, one cannot ignore the influence of trauma. Substance use disorders and PTSD often co-occur, with 1 study finding that up to 46% of patients with PTSD also meet criteria for a substance use disorder.5 Successful treatment of both disorders simultaneously is critical for patient improvement.
Ms Harris is initially started on sertraline for PTSD. Given her distrust of others and perceived failure of another selective serotonin reuptake inhibitor, considerable time is spent in psychoeducation surrounding the role and effects of medications in her treatment plan. She is also started on naltrexone for alcohol use disorder. Trazodone is used for sleep initiation difficulties.
In subsequent visits, the patient reveals that she is having nightmares surrounding the physical abuse by her ex-husband. She reports that the dream frequency has not changed with the initiation of her other medications. Doxazosin is added. Although more research is needed in patients with comorbid PTSD and alcohol use disorder, doxazosin has had some promising results when studying these illnesses separately.6
Other treatment options aimed at addressing her anxiety, such as hydroxyzine and gabapentin, are discussed but declined by the patient because of a fear of daytime sedation. Topiramate is also discussed, as it has shown promise in patients with cooccurring PTSD and alcohol use disorder, although additional studies are needed.7 Ultimately, this medication is also omitted from the treatment plan because of the potential for cognitive deficits, which could impair her ability to participate fully in her substance use treatment program.
The shelter helps Ms Harris remain adherent with her medications with frequent reminders and scheduled medication times. She participates in cognitive behavioral therapy (CBT)-based substance use treatment classes as well as group and individual therapy. She engages in prolonged exposure for her traumas. Over many weeks, Ms Harris begins to trust her psychiatrist and engage in more peer support activities. Her emotional and physical reactivity improve. With the help of the shelter’s case manager, Ms Harris is able to obtain work in the retail industry. As graduation approaches, she becomes more anxious. Her psychiatrist initiates a CBT-based model aimed at addressing her cognitive distortions surrounding her ability to be successful outside a structured setting. Ms Harris graduates from the substance treatment program and moves into an apartment.
She is followed closely by her psychiatrist after graduation. Immediately following her transition out of the shelter, the patient reports a recurrence of anxiety and sleep disturbance. In addition, she reports a relapse after being offered alcohol by a well-meaning neighbor. While initially struggling with significant shame and guilt, the patient is able to abstain from further use. Trazodone is transiently increased, and Ms Harris continues to address her anxiety in therapy with positive effect.
After many months, Ms Harris becomes romantically involved with a neighbor at her apartment complex. She reports an improvement in her anxiety and continued sobriety in the weeks following the start of their relationship. She is lost to follow-up.
Ms Harris returns to the clinic after 1 year. She reports that her boyfriend did not support her use of psychiatric medications and advised her to stop them. He soon became increasingly emotionally abusive and the patient relapsed on alcohol. Two weeks ago, he sexually assaulted her after she declined to have intercourse. She has not told anyone about the assault but ended the relationship. She reports feeling fearful because the man still lives in her apartment complex.
Her psychiatrist provides emotional support while encouraging the patient to report the assault to the police and consider seeking a restraining order in accordance with state law. She is also encouraged to obtain urgent gynecologic care and is given information about a local family violence shelter. While the patient declines to report the incident to the police or seek resources from the family violence shelter, she agrees to seek gynecologic care. The patient restarts her medications and is able to taper off alcohol as an outpatient.
Working with homeless patients can be exceedingly rewarding. Patients such as Ms Harris can and do improve at a remarkable rate with the appropriate support and treatment. However, there are also challenges facing psychiatrists who work with homeless patients (Figure), notably vicarious trauma. Psychiatrists in this area are inherently exposed to personal reports of trauma repeatedly throughout the day. One study in Canada showed rates of PTSD in helping professions related to homelessness were 2 to 3 times higher than what were found in other frontline professions such as police work and emergency services.8 Therefore, it is imperative that those working with this patient population actively engage in their personal wellness and ensure they are receiving support from their institution.
Dr Williams is assistant professor at the Meninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She specializes in homeless populations with cooccurring psychiatric illnesses and serves as the departmental lead medical students elective officer and associate clerkship director.
1. Hepp J, Schmitz SE, Urbild J, et al. Childhood maltreatment in associated with distrust and negatively biased emotion processing. Borderline Personal Disord Emot Dysregul. 2021;8(1):5.
2. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. Substance Abuse and Mental Health Services Administration; 2014.
3. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.
4. Doran KM, Rahai N, McCormack RP, et al. Substance use and homelessness among emergency department patients. Drug Alcohol Depend. 2018;188:328-333.
5. Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord. 2011;25(3):456-465.
6. Back SE, Flanagan JC, Jones JL, et al. Doxazosin for the treatment of co-occurring PTSD and alcohol use disorder: design and methodology of a randomized controlled trial in military veterans. Contemp Clin Trials. 2018;73:8-15.
7. Flanagan JC, Korte KJ, Killeen TK, Back SE. Concurrent treatment of substance use and PTSD. Curr Psychiatry Rep. 2016;18(8):70.
8. Waegemakers Schiff J, Lane AM. PTSD symptoms, vicarious traumatization, and burnout in front line workers in the homeless sector. Community Ment Health J. 2019;55(3):454-462.